The May 2003 issue of the Bulletin of the American College of Surgeons included a landmark article detailing the beginnings of a successful rural surgery training program.1 Subsequently, several additional programs have emerged, each with its unique characteristics, to address the challenge of training rural general surgeons. In 2015, Mayo Clinic’s campus in Rochester, MN, began its integrated community and rural training track in the general surgery residency program. Building on prior research in the field, the developers of the track had a particular skill set in mind in developing the program.
The initial goal of Mayo’s general surgery track was to address the growing shortage of community surgeons, specifically rural surgeons. The developers believed that a well-crafted residency should eliminate the need for a community track fellowship or transition to practice programs for physicians interested in community and rural practice. As such, the track was named the integrated community and rural general surgery track. This article highlights lessons learned in the first three years of the program that can be used with other previously produced works to guide the development of future training programs at other medical institutions.
Why we did it
The needs and express challenges of rural surgery practice in the U.S. have been well documented in several issues of the Bulletin2,3 and in Surgical Clinics of North America.4 These challenges also have been recognized by other stakeholders and publications that have a particular focus on advocacy efforts as related to rural surgery.5
The primary issues in rural surgery come back to isolation…. The available staff at a nonurban center differs widely but often consists of a core of primary care physicians and one or two general surgeons.
Thompson and colleagues calculated the number of general surgeons as 4.67 surgeons per 100,000 persons in small or isolated rural areas, versus 6.53 per 100,000 in urban areas.6 They concluded that general surgeons constitute a critical component in the medical workforce throughout rural areas in the U.S. Furthermore, the estimated number of rural general surgeons per 100,000 persons declined by 21 percent from 1981 through 2005.7 The need for quality rural surgery training programs is supported by the continued decline of surgeon numbers in U.S. rural areas.
The primary issues in rural surgery come back to isolation. In a rural hospital, full-time surgical subspecialists, such as obstetricians–gynecologists, orthopaedic surgeons, urological surgeons, otolaryngologists–head and neck surgeons, and plastic surgeons, may be in less demand. A rural health care staff can function without a gastroenterologist and almost certainly will not include an interventional radiologist. In fact, subspecialists trained in general surgery who completed fellowships in vascular, thoracic, pediatric, cancer, endocrine, hepatobiliary, breast, trauma, and colorectal surgery also are less likely to be found in rural practice. The available staff at a nonurban center differs widely but often consists of a core of primary care physicians and one or two general surgeons. The rural health care setting often leads to other workforce issues, such as lack of mentorship, excessive on-call hours, a perceived lack of desired local recreational activities, location preferences of significant others, and difficulty in keeping up with technical and intellectual advances.
With these variables in mind, Mayo’s focus in providing a rural track was to improve the training and thus the confidence of surgical residents freshly out of training. The track developers wanted to give these residents the skills they would need to sustain a rural practice by becoming lifelong learners with a link to academic practices for ongoing support (see the track structure in Table 1).
Table 1. The Mayo Clinic Integrated Community and Rural General Surgery (Gen Surg) Track
The differences between a large urban practice and a general rural practice are numerous. In the large urban hospital, for example, general surgeons are not called on to set fractures, perform cesarean sections, or operate on a testicular torsion or peritonsillar abscess, and sometimes they are not even called on to perform endoscopy, thoracoscopy, or elective colon resection. However, a small rural hospital that lacks the same array of specialists needs health care professionals who can provide these important services.8
The spoke-and-hub model has emerged as a general surgery option, particularly in a rural setting, and expedient patient transport in these often remote areas has improved. Still, these approaches can be impeded by extreme distances in the rural west and uncooperative weather in the north. In addition, transport adds major cost and inconvenience for patients who prefer to continue their care at the local hospital.9 Perhaps more importantly, transport out of town to receive health care will do little to revive the vibrant and bustling rural U.S.
Previous researchers have sought to determine which surgical residents are most likely to pursue practice in a rural environment. They report that statistically significant correlations are primarily based on the individual’s background.
The skill set needed in the rural surgery environment is distinct and can be specifically taught through senior-level rotations in surgical subspecialties. This approach deviates from most training programs that simply touch on these skills in the first or second year of residencies. This model teaches competency in basic subspecialty procedures at a time in residents’ training when they are more likely to focus on how to do the procedures and, more importantly, to develop the skills to do the procedures confidently in practice. An added benefit is the insight gained concerning which procedures can be performed safely in their rural hospitals and when it is best to refer these patients elsewhere.
The Mayo Clinic Health System (MCHS) is a large network that spans across U.S. state lines and encompasses a primarily rural geographic area. Many people throughout the world have heard of Mayo Clinic in Rochester, but few patients know that MCHS hospitals are located in the smaller, more rural communities of Mankato, Owatonna, and Red Wing, MN, as well as La Crosse and Eau Claire, WI. However, the people who live in and near these locales know of the hospitals that provide necessary services to patients interested in obtaining their care locally—for whom the thought of traveling to Rochester seems excessive when local options are available. Indeed, previous studies have shown that many patients prefer to accept second-line therapy—or to forgo care altogether—before making the financial and time commitments of travel to a larger commercial center.9 Rather than offer second-line therapy, the goal of Mayo Clinic is to deliver cutting-edge, appropriately triaged care at all of its sites.
The rural track uses many of the MCHS campuses in rural Minnesota and Wisconsin for its various clinical rotations. Our goal was to ensure that Mayo-trained general surgeons would see the benefits of practicing at rural hospitals throughout the U.S.
How we did it, and what we’ve learned
We have learned several lessons in the process of developing and implementing the MCHS rural surgery track. We share them here to serve as guideposts for other health care systems looking to assist in training the next generation of rural general surgeons.
Address one goal at a time
A main observation in the development of this program was that perhaps dual lofty goals are too much for a single resident track to bear. The rural track is designed beautifully with the altruistic goal of addressing the needs of the most rural segments of the U.S. It comprises all necessary components and has been expanded since its inception to include a more robust endoscopy experience. In the short term, residents adjust or develop rotations to suit their desired goals. In the long term, the expansion of the residency to both a community track and a rural track may be a better option.
As the program developed, we saw progressive curiosity from applicants interested in a global health care preparatory training. Although overlap between rural and global training needs is easy to see, we believed that the ultimate goals and product look different. Many trainees interested in global health-related training do not fit the model of surgical trainees who will be interested in entering practice in a rural or community setting. We have chosen to focus on the rural or community goal in our initial efforts to develop a rural track.
Tailor training to the program’s intrinsic qualities
This program offers the best of both worlds, combining the quaternary care of Mayo Clinic’s Rochester campus with the breadth of the MCHS. Each training program has its own intrinsic strengths and weaknesses. Some program directors believe that tertiary care centers, where most of the surgical training occurs, do not represent the environment in which rural surgeons practice, and therefore a specific curriculum to train future rural surgeons is beneficial.10 One obvious characteristic of Mayo Clinic is the high-level, complex, coordinated care that surgical specialists frequently administer. Cancer operations involve multiple subspecialties and include laparoscopic and robotic Whipple procedures. In this environment, subspecialty surgical fellows could easily interfere with the solid broad-based training of a general surgeon.
To protect the exposure of residents to their designated subspecialties and maximize the skills they are likely to continue to put into practice, we have planned that senior-level rotations in the subspecialties will be completed exclusively within the MCHS during an emersion year. On the MCHS rotations, the general surgery resident frequently is the only resident in the county. As a result, the resident is positioned to take advantage of full exposure to operating room (OR) cases, clinic visits, emergency department consults, and a dedicated surgical resident clinic during the general surgery rotation. Additionally, this approach ensures that the resident has exposure to the bread-and-butter cases in their subspecialty, and it protects the trainee’s time from the uncommon and high-level subspecialty cases that are more often seen at Mayo Clinic’s Rochester campus, where such cases may consume an entire day.
For example, an otolaryngology rotation in a rural track should consist of the following: tonsillectomy and adenoidectomy, placement of tympanostomy tubes, emergency department call, thyroid resections, tracheostomies, foreign body removal, epistaxis management, and the occasional parotid operation. An ear, nose, and throat rotational experience at the Rochester campus would be much different, with an altogether separate case mix and with residents and fellows in competition for the cases. The mix at Rochester might include radical head, neck, and face procedures and endoscopic operations—procedures that would rarely be performed at a rural surgery center.
Case volume matters
Case volume is an important aspect of a robust surgical training experience. Prior guidelines suggest that deliberate practice and quality case volumes are required for surgical competency,11 and therefore site selection is crucial. Although the rural track trains surgeons to work in critical access locations, certain sites may not be the best for training. A short rotation in the most rural sites can have the benefit of simple exposure to the rural surgical environment, but for training purposes a busier hospital with full-time subspecialists and no other residents may be the ideal.
Most (65 percent) of our rotations outside the Rochester campus take place at the La Crosse hospital. Since 2009, third-year residents have gone to this site for a general surgery rotation. The Accreditation Council for Graduate Medical Education case logs were evaluated for these six- to seven-week rotations. The logs showed that per rotation, residents had 80 to 140 junior surgeon cases—two or three times the standard amount on the Rochester campus. Cases ranged from laparoscopic cholecystectomies to lung resections, carotid endarterectomies, and spine exposures.
Several factors influence this difference in case volume, including less case acuity and length, the lack of resident competition, and more efficient OR use. Cases that are exclusive of residents in all specialties are seen every day. The unrivaled success at Mayo Clinic’s campus in La Crosse has set the stage for development of the rural track residency.
Obtain administrative and clinical support
A working relationship has been established at each MCHS site. Site visits by the rural track program director, who is based in La Crosse, are necessary to ensure rotation quality and teaching faculty engagement. Importantly, administrative decisions are made well in advance, administrative support is available at all levels, and faculty support of resident training is accessible. To date, all sites have been receptive to surgical trainees and to the idea of a rural track generally. In fact, MCHS site participants continue to volunteer to work with our residents, including subspecialists who have quickly allowed graded responsibility to trainees appropriate to their level of personal training.
Include acute endoscopy skills
Gastrointestinal tract endoscopy can comprise more than 50 percent of a surgeon’s case volume in a rural environment. All general surgery residents at Mayo Clinic complete a rotation in Owatonna, exclusively for a robust endoscopy experience. At the Owatonna site, general surgeons do endoscopy five days per week, with a total of 1,700 to 1,800 endoscopies annually. In 2017, second-year rural track residents performed an average of 131 endoscopies and participated in 78 major cases during a seven-week Mayo Clinic endoscopy rotation. One identified challenge to the gained experience is that most of these endoscopies were for nonacute pathologic characteristics.
This experience level is excellent for learning the technical skill of endoscopy. However, in rural practice, the surgeon is asked to perform interventional endoscopy for bleeding and obstruction, in addition to screening colonoscopy and diagnostic esophagogastroduodenoscopy. A dedicated rotation on a team in interventional gastrointestinal tract endoscopy at a tertiary center could improve the resident’s exposure to acute care endoscopy.
Plan recruitment carefully
Previous researchers have sought to determine which surgical residents are most likely to pursue practice in a rural environment.12 They report that statistically significant correlations are based primarily on the individual’s background. Rural experiences at high school, college, medical school, and residency, as well as enjoyment of rural activities and a spouse from a rural area, are associated with future practice as a rural surgeon.12 This observation raises the central concern that true recruitment for the rural surgery subspecialty should begin at the high school level by community organizations that identify a need for a surgeon. For a residency program, the timing is too late if recruitment is at the medical school level. Continually, a subset of graduating medical students grew up on a farm or in a rural environment and would prefer to practice in a rural area. The early identification of these students and their match to a rural track is central to the subversion of the “brain drain” and placement of surgeons into critical access hospitals around the country.
Prepare for housing and travel needs
Housing and payment should be planned well in advance of specific rotations. The travel from site to site can be challenging for surgical trainees with young families, and arrangements should be made for families to accompany trainees whenever possible. This required travel should be discussed with applicants during the interview season. Housing for the Mayo Clinic rural track includes a rented apartment at one site and an extended-stay hotel at other sites. With time and as funds allow, apartment housing may become standard at most sites.
The challenges in rural surgery practice are great, and a new generation of rural surgeons is needed to meet these challenges.
The challenges in rural surgery practice are great, and a new generation of rural surgeons is needed to meet these challenges. Training of new surgeons continues to be a topic of discussion. This article details one model for this training and discusses the benefits and shortcomings of this approach. Follow-up is required to determine the efficacy of the placement of trainees from this surgical track into rural environments and to monitor their eventual practice patterns.
To date, we have recruited five trainees into the program (one per year). The first trainee will graduate in June 2020. All trainees are on track to pursue careers in rural locations. As the program has developed, we have adjusted which sites are involved in which postgraduate years to optimize the experiences based on technical skill versus case mix. The program will likely expand the number of graduates per year once we are certain the program is designed appropriately to ensure our graduates are set up for success.
- Hunter JG, Deveney KE. Training the rural surgeon: A proposal. Bull Am Coll Surg. 2003;88(5):13-17.
- Long S. Dispatches from rural surgeons: Rural surgery: High pressure but rewarding. Bull Am Coll Surg. 2017;102(1):55-57. Available at: http://bulletin.facs.org/2017/01/rural-surgery-high-pressure-but-rewarding/. Accessed September 23, 2019.
- Puls MW. Dispatches from rural surgeons: Shortage of rural surgeons: How bad is it? Bull Am Coll Surg. 2018;103(4):52-55. Available at: http://bulletin.facs.org/2018/04/shortage-of-rural-surgeons-how-bad-is-it/. Accessed September 23, 2019.
- Pathman DE, Ricketts TC. Interdependence of general surgeons and primary care physicians in rural communities. Surg Clin North Am. 2009;89(6):1293-1302.
- Cogbill TH, Cofer JB, Jarman BT. Contemporary issues in rural surgery. Curr Probl Surg. 2012;49(5):263-318.
- Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural America. Arch Surg. 2005;140(1):74-79.
- Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981–2005. Arch Surg. 2008;143(4):345-350.
- Harris JD, Hosford CC, Sticca RP. A comprehensive analysis of surgical procedures in rural surgery practices. Am J Surg. 2010;200(6):820-825.
- Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF, Jr. Patient preferences for location of care: Implications for regionalization. Med Care. 1999;37(2):204-209.
- Burkholder HC, Cofer JB. Rural surgery training: A survey of program directors. J Am Coll Surg. 2007;204(3):416-421.
- Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 Suppl):S70-S81.
- Jarman BT, Cogbill TH, Mathiason MA, et al. Factors correlated with surgery resident choice to practice general surgery in a rural area. J Surg Educ. 2009;66(6):319-324.